Sen. Rand Paul’s Serious Diagnosis: Chest Contusion

Sen. Rand Paul was recently the victim of an assault that resulted in chest trauma. Initially, he confirmed that he had suffered broken ribs and was obviously experiencing significant discomfort. His X-ray later showed a pleural effusion —a significant diagnosis. It was later learned that the damage was even more extensive — he was diagnosed with a chest contusion.

Paul has been forced to refrain from working for a number of weeks, though he did make some limited media appearances to reassure individuals that he was recovering and would resume work as soon as his doctors gave him the go ahead.

How can chest trauma resulting from a single simple incident like this altercation result in such a crippling state?

It actually happens more frequently than you’d think.

According to the Centers for Disease Control and Prevention (CDC) there were more than 130,000 deaths from chest trauma in 2013. Chest injury can present in a variety of ways. It can occur as a penetrating trauma, such as a stabbing or blunt trauma, which is what happened to Paul. While a stabbing or gunshot wound is a very specific injury, blunt chest trauma, based on the specific area, can affect a number of different components of the chest wall. As observed in Paul’s case, the consequences can also be felt hours or even days later.

The chest contains vital organs including the heart, great (blood) vessels, and the lungs, and they are all protected by the rib cage. Contusion occurs right on the site of the (blunt) impact, and the resulting damage can occur on the chest wall at this site, but also has the potential to harm the lungs behind the ribs. The lung damage can occur via different mechanisms:

Similar to brain trauma, the lungs can be injured by the “countercoup effect,” where the impact is actually on the opposite side from the affected lung area.

Shock wave can travel through the chest by way of the curved ribs and concentrate the damaging energy on the back area.

When the hard tissue of the ribs clashes with soft tissue, such as the lungs, there is air and fluid leakage. In the case of Paul the pleural effusion resulted due to the presence of fluid leakage between the lungs and the chest, or pleural space.

Sometimes a tear is caused in the air sacs or alveoli from the sheer force of the blunt trauma, and there is a leak of air from the lungs causing a pneumothorax.

Then there are rib fractures. In this particular case, it’s not just chest contusion, but also breaks in the rib bones which can cause further damage (and significant pain). The risk of suffering fractures is determined in part by the force of impact and by the flexibility of the tissue. Children’s ribs are actually more elastic and their rib cartilage is less dense, while in older people the opposite is true. So, adults would be more likely to suffer “breaks.” In the senior population — where there is likely to be osteoporosis — fractures can occur with minimal impact.

If the ribs are actually broken, it is possible that one or more of the fractured ribs will pierce the lungs or some of the arteries. This will result in even more pain and additional complications

Reporters and doctors who covered Paul’s story also mentioned that he might have developed a condition called “slipping ribs.” This condition has the potential to be more even serious than rib fractures.

Slipping rib syndrome occurs when the cartilage or ribs move out of position, similar to a dislocation. The condition can present as the ribs slipping out of the socket connection to the breast bone. This situation is potentially quite serious because unlike rib fractures, where the bones remain in their respective place and eventually heal, the dislocated ribs may actually remain in the abnormal position permanently, distorting the chest and making every breath painful. Arm and chest movements can also result in these broken or slipped ribs moving and causing sudden, acute pain.

Slipping syndrome is often difficult to diagnose because the X-ray results may not be as obvious as is in a fracture, and the symptoms can also resemble other conditions. Key to the diagnosis is the persistence of symptoms and especially pain complaints over a more prolonged period of time than one might expect with simple rib fractures.

Rib fractures are also categorized as displaced or non-displaced, indicating whether the original alignment of the ribs is maintained and therefore likely to unite with the different fragments. Worst case scenario is when the fragments of the broken ribs move in opposite directions during the breathing process — a condition known as “flail chest.”

Unfortunately, there is no specific treatment for rib fractures except measures that help to limit, avoid, or correct potential complications such as fluid accumulation, respiratory failure, air leak, or pneumothorax. Sometimes the doctor will insert a chest tube into the space surrounding the lungs to remove accumulating fluid or to evacuate excess air, which allows the lungs to re-expand.

Although breathing is painful, it’s important to encourage the patient to breathe deep regularly and this is accomplished with the use of devices called incentive spirometers. Not engaging in deep-breathing can cause the patient to develop further lung collapse due to the lack of air movement.

Chest trauma can occur in many situations. Most commonly we see it in vehicle accidents, when the chest gets the brunt of the impact (against the steering wheel or from the air bag that’s deployed) even with the use of seat belts. It also commonly occurs during recreational activities (think football or hockey impact) and can also occur during regular sports activities when two people collide. It’s a risk for many individuals with very active lifestyles.

In the case of Paul, he simply experienced an attack from behind by another individual and the subsequent trauma was actually impressive given the situation. It was a case of being in the wrong place at the wrong time, with a well-placed blunt force trauma that resulted in significant injury. Luckily, he was able to seek help from experienced, skilled health-trauma specialists who identified all aspects of the trauma and instituted appropriate treatments.

With time, Paul should be able to recover and resume his full responsibilities.

Eli Hendel, M.D., is a board-certified internist/pulmonary specialist with board certification in Sleep Medicine. An Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations, his areas include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases. Favorite hobby? Playing jazz music. Find him on Twitter @Lung_doctor.